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Coordination of Benefits between Two Drug Plans

Last Modified: 1/16/2013 5:33:22 PM

Article: KB00130

Coordination-of-benefits rules are used by most group health plans to determine the order and amount of payment when a member has two or
more drug plans. When benefits are coordinated, the primary plan typically pays its benefits in full while additional plans (secondary or
tertiary plans) normally pay reduced benefits.

Once HMSA determines the order of payment, we calculate whether there’ll be any portion for you to pay after your primary plan pays. If
your secondary plan is an HMSA plan, the amount of payment by your secondary plan won’t exceed the amount that would’ve been paid
if it were your only plan.

You may have an out-of-pocket cost even after both of your drug plans pay. Whether your primary plan is HMSA or another carrier’s plan,
your secondary HMSA plan will pay the lesser of the amounts listed below:

The eligible charge for the drug, minus the amount paid by the primary plan*, or

The amount the secondary plan would’ve paid if it were the only plan.

*Note: For HMSA Select drug plans, the Other Brand Name Cost Share you owe
will first be subtracted from the benefit payment. You are responsible for the Other Brand Name Cost Share: it is owed in addition to the copayment.
For example, let’s say your secondary plan is an HMSA Select drug plan. In this case, your responsibility for Other Brand Name drugs is a
$30 copayment, plus a $45 cost share.
When coordinating benefits, the $30 copayment may be covered or reduced, but you’ll still owe the $45 cost share. Please read
Plan certificates describe additional coverage for more information.